Vision Screening Online Training Program
Module 1: Introduction
After reading these modules, the participant will be able to:
- Describe the importance of vision screening and early identification
- Identify the Child and Teen Checkups (C&TC) vision screening procedures for children and youth ages 0 through 20 years
- Identify child and family history factors that indicate a risk for developing visual deficits
- Identify visual acuity screening procedures using a standardized tool
- Document vision screening results
The purpose of vision screening
In the childhood years it is important to detect any vision problems that may impair a child's ability to learn. The screening process can help determine which infants and children may need further diagnostic assessment and referral to a vision professional.
C&TC Vision screening requirements
A vision risk assessment and history should be performed at all visits for all ages. A thorough inspection of the eye is required as part of the C&TC physical exam for all ages. Visual acuity screening is required beginning at 3 years of age.
A vision history/risk assessment for vision problems includes considering the child's medical history, family history, and other considerations that may impact visual health and is performed at all visits before age 3 years. A thorough assessment of risks indicated by the child and family's vision health history is an important part of the child's checkup because many eye conditions are hereditary. A referral to an eye care professional may be based on the family and child's history alone.
A through eye inspection during the physical exam includes external inspection and observation, corneal light reflex, unilateral cover test and external ocular movements [also called fix and follow]), red reflex and pupillary light response.
Visual acuity screening should be performed starting at age three years using a recommended age appropriate vision chart.
Who should screen?
In the Child and Teen Checkups program, components of vision screening are provided by either the health care provider (HCP - definition includes physician, nurse practitioner, physician's assistant, or registered nurse [RN] with training in vision screening from MDH) or the medical assistant or licensed practical nurse (LPN). For example, the vision health history, external inspection and observation, corneal light reflex, unilateral cover test and external ocular movements [also called fix and follow], red reflex and pupillary light response are performed by the HCP. Screening with visual acuity charts and stereo acuity test is often conducted by the medical assistant or LPN. For more information regarding C&TC roles, review the following C&TC fact sheets: Vision Screening, Health History, and Physical Exam.
Screening is also provided in Minnesota for Early Childhood Screening for public school kindergarten entry (legislative mandate), in schools during or after kindergarten (non-mandatory), and in Head Start programs. This web training module for vision screening has been developed to educate those who will be screening from each of these areas. In regards to C&TC screening, each of the screening procedures in this training module indicate who is the most appropriate to administer the screening tests.
Why Vision Screening is important
Much of what we learn comes through the visual senses . Vision affects the performance of the whole child. What the child is able to see influences the child's performance and adjustment in school, society, and overall health . Vision screening is important because it leads to the identification of children with vision abnormalities such as visual acuity and muscle balance problems.
Impaired vision in children can contribute to the development of learning problems which may be prevented or alleviated through early identification and intervention. Children with impaired vision often are not aware of their impairment; therefore, they do not complain or seek help. If they have always seen things in a blurred or distorted way, they accept the imperfect image without question. It is up to adults responsible for children's health care and education to assure that children have their vision screened on a regular basis.
What kind of vision problems are we screening for?
In infants and toddlers, positive child and family risk factors may indicate the need for further evaluation by an eye care professional because the child may develop an eye condition or vision problem that could go undetected without a thorough exam and follow-up . A thorough examination of the eye structure (internal inspection with an ophthalmoscope) by trained health care personnel is extremely important in catching vision problems, especially in children under the age of three years (the age when visual acuity screening can usually be reliably performed).
Nerve connections in the eye are not fully developed until after the age of 8 years old . Before full visual development is reached, it is very important to screen for conditions that can result in amblyopia (lazy eye) if not detected and treated early . Amblyopia is a condition that can cause a permanent loss of vision that is not able to be corrected with glasses or contacts. Amblyopia usually develops due to an existing condition that causes visual acuity deficits. Amblyopia can often be reversed if the underlying vision problem is caught and treated before age 6 or 7 years old.
The earlier these problems are detected and treated, the better the outcome.
Conditions that contribute to the development of amblyopia include:
- Organic defects: retinoblastoma (cancer of the eye), cataracts or glaucoma (cloudy eye/lens), and ptosis (droopy eye lid).
- Strabismus (crossed eyes).
- Anisometropia (a difference in visual acuity of each eye).
- Refractive errors (being nearsighted, farsighted, or having astigmatism [distorted vision at both near and far]).
Generally, nearsightedness first occurs in school-age children. Because the eye continues to grow during childhood, it typically progresses until about age 20 . Once children reach puberty, about 20% of children may develop nearsightedness; this too requires referral to an eye care professional .
Throughout all these years, it is also important to protect the eyes from injury from the sun or sports and play.
How is a child affected by vision loss?
If it is a visual acuity problem, a child with near-sightedness (myopia) will not see objects at a distance well. On the other hand, a child with farsightedness (hyperopia) will not see near objects clearly. If the child has astigmatism, they will see things blurry, whether the image that they are looking at is near or far.
Any condition that prevents both eyes from working as a team (i.e. having the ability to bring the objects seen with each eye into one image) during the first decade of life can cause lazy eye (amblyopia). The detection of amblyopia at an early age is a very important aspect of the routine eye examination/screening in the pediatric population. Left undetected and untreated, amblyopia may lead to irreversible visual deficits, especially permanent problems related to depth perception and the ability to see three dimensionally. Therefore, early identification and referral to an eye doctor is extremely important.
Vision Screening Tips
In young children (under age 5) it is important to screen efficiently with a steady pace due to children's limited attention span. It is also very helpful to have several toys or attention grabbers. Try to make the vision screening fun for the child. For optimal screening, make every effort to minimize distractions in the screening environment. If screening is done in a large room, one method of minimizing distractions would be to have a curtain separating the children being screened.
Children who are familiar with screening will move through a screening procedure with more ease in comparison to children who are encountering a screening event or test for the first time. In regards to specific screening tests, it is possible to condition the child beforehand for individual tests. For example, there are puzzles and preparation charts available for visual acuity tests in the Minnesota Vision Screening Training Manual. The visual acuity test is often the most time consuming during screening, so if conditioning the child to the tests is possible, screening times generally improve.
Expert Panel of Childhood Vision Screening
The recommendations contained in this module were developed based on recommendations put forward by a panel of Minnesota-based vision screening experts who came from a cross-section of screening progrms and professional organizations. The Expert Panel on Childhood Vision Screening was convened by the MDH Community and Family Health Division and met four times between April and June, 2015. The expert panel reviewed national vision screening recommendations from the American Association of Pediatric Ophthalmology and Strabismus (AAPOS) and others, revised the vision screening procedures, and developed a guideline document. Throughout the module, the recommendations of this expert panel will be presented and may be referenced as the "Minnesota Vision Screening Procedures".
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